Detection and management of coronary artery disease in patients with rheumatologic disorders.

Coronary heart disease causes significant morbidity and mortality in our society and is more common in patients with some rheumatic disorders. A thorough history is the most essential element in assessing patients with chest pain syndrome or dyspnea who are at risk of harboring coronary artery disease. Based on the level of suspicion, a noninvasive test is commonly ordered to confirm the diagnosis. If a patient is active and can exercise, then treadmill or bike stress echocardiography is recommended. In addition to assessment of valvular, pericardial, and myocardial function at rest, stress echocardiography permits direct visualization of left ventricular cavity enlargement or wall motion abnormalities, which imply significant myocardial ischemia. If the echocardiography laboratory does not have sufficient expertise or experience with this technique, then exercise thallium is the next study of choice. If a patient is inactive or is unable to exercise, then dobutamine stress echocardiography is recommended. For patients who are in atrial fibrillation, have permanent pacemakers, who cannot augment their heart rate to a minimum of 85% MPHR, dipyridamole thallium is an acceptable alternative. An ischemic response in a symptomatic patient in most cases requires further evaluation with cardiac catheterization. Based on the patient's clinical presentation and physiologic and anatomic findings, important therapeutic decisions can then be made.